ing alone, in a subsidized apartment off
Fillmore Street. In California, emanci-
pated foster children are given a sum-
mary of their case file, which meant that
Sullivan had just been handed an official
history of her rootless adolescence. "It
brought up a lot of emotions," she told
me. "I read it, and I kind of wanted to
cry. But I was just, like, 'It's over with.'"
The most painful memory was of the
day, in fifth grade, when she was pulled
out of class by a social worker
she had never met and driven
to a strange new home. It was
months before she was able to
have contact with her father.
"I still have dreams about it,"
she told me. "I feel like I'm
going to be damaged forever."
I asked Sullivan to ex-
plain what that damage felt
like. For a teen-ager, Sulli-
van is unusually articulate
about her emotional state-
when she feels sad or de-
pressed, she writes poems-and she
evoked her symptoms with precision.
She had insomnia and nightmares, she
said, and at times her body inexplicably
ached. Her hands sometimes shook
uncontrollably. Her hair had recently
started falling out, and she was wearing
a pale-green head scarf to cover up a
thin patch. More than anything, she
felt anxious: about school, her daugh-
ter, even earthquakes. "I think about
the weirdest things," she said. "I think
about the world ending. If a plane flies
over me, I think they're going to drop
a bomb. I think about my dad dying.
If I lose him, I don't know what I'm
going to do." She was even anxious
about her anxiety. 'When I get scared, I
start shaking," she said. "My heart starts
beating. I start sweating. You know how
people say, 'I was scared to death'? I get
scared that that's really going to hap-
d "
pen to me one aYe
Sullivan encountered Nadine Burke
at a moment when Burke was just be-
ginning to think deeply about the phys-
ical effects of anxiety. She was im-
mersing herself in the rapidly evolving
sciences of stress physiology and neuro-
endocrinology, staying up late read-
ing journals like Molecular Psychiatry
and Nature Neuroscience. Burke had just
learned of a pioneering study, con-
ducted in San Diego, on the long-term
26 THE NEW YORKER, MARCH 21, 2011
health effects of childhood trauma, and
its conclusions had led her toward a new
way of thinking-not just about her
clinical practice but about the entire
field of pediatric medicine.
As she listened to Sullivan, Burke
found herseIfinching toward a diagnosis
that, a year earlier, would have struck her
as implausible. What if Sullivan's anxiety
wasn't merely an emotional side effect
of her difficult life but the central issue
affecting her health? Accord-
ing to the research Burke had
been reading, the traumatic
events that Sullivan experi-
enced in childhood had likely
caused significant and long-
lasting chemical changes in
both her brain and her body,
and these changes could well
be making her sick, and also
increasing her chances of se-
rious medical problems in
adulthood. And Sullivan's
case wasn't unusual; Burke
was seeing the same patterns of trauma,
stress, and symptoms every day in many
of her patients.
Two years after Sullivan's first visit,
Burke has transformed her practice. Her
methodology remains rooted in science,
but it goes beyond the typical boundar-
ies of medicine. Burke believes that re-
garding childhood trauma as a medical
issue helps her to treat more effectively
the symptoms of patients like Sullivan.
Moreover, she believes, this approach,
when applied to a large population,
might help alleviate the broader dys-
function that plagues poor neighbor-
hoods. In the view of Burke and the re-
searchers she has been following, many
of the problems that we think of as so-
cial issues-and therefore the province
of economists and sociologists-might
better be addressed on the molecular
level, among neurons and cytokines
and interleukins. If these researchers are
right, it could be time to reassess the re-
lationship between poverty, child devel-
opment, and health, and the Bayview
clinic may turn out to be a place where
a new kind of pediatric medicine is tak-
ing its tentative first steps.
'With someone like Monisha, we
can help her recognize the neurochem-
ical dysregulation that her childhood has
produced in her," Burke told me. "That
will reduce her impulsivity, it will allow
her to respond more calmly to provoca-
tion, it will help her make better choices.
She'll have a better life."
I n 2005, when Burke completed her
medical residency, at a children's hos-
pital on the campus of Stanford Univer-
sity, she was an idealistic twenty-nine-
year-old with a medical degree from
the University of California at Davis and
a master's in public health from Har-
vard. She was recruited by the California
Pacific Medical Center, a private hospi-
tal group, to take on a vaguely defined
but noble-sounding job: identifying
and addressing health disparities in San
Francisco, where the poverty rate for
black families is five times as high as that
for white families. Much of the city's
African-American population lives in
Bayview- Hunters Point, a largely indus-
trial area that has a sewage-treatment
facility and a sprawling Superfund site.
Rates of congestive heart failure are
nearly five times as high in Bayview-
Hunters Point as in the Marina district,
a few miles away. Before Burkès clinic
opened, there was only one pediatrician
in private practice in a community with
more than ten thousand children.
At Harvard, Burke had studied
health disparities, and she knew what
the public-health playbook recom-
mended: improving access to health
care, especially primary care, for low-
income families. She persuaded her new
bosses at California Pacific to let her
open a clinic in Bayview- Hunters Point
that would accept all patients, regardless
of their ability to pay. She found some
empty office space on Evans Avenue,
across from a giant mail-sorting facility,
and had the place remodelled and re-
painted in bright colors.
When the clinic opened, in 2007,
Burke focussed on health issues that par-
ticularly plagued poor children: asthma,
obesity, vaccination rates. In just a few
months, she made significant headway.
"I t turned out to be surprisingly easy to
get our immunization rates way up and
to get our asthma hospitalization rates
way down," she told me. And yet, she
explained, "I felt like we weren't actually
addressing the roots of the disparity. I
mean, as far as I know, no child in this
community has died of tetanus in a very,
very long time."
Burke found herself thinking in-